8/9/19 jvogel, revised 2/10/20

PAIN MANAGEMENT INITIAL EVALUATION

Patient name: _______________________________

Date of Birth: ___________ Date: ______________

How long have you been having SEVERE problems with pain? _______________________

Was it the result of an injury or accident? _____ If so, what happened?

_____________________________________________________________________________

Where is your pain MOST SEVERE most of the time? ______________________________

Timing of Pain:

How often do you have your pain? (please check one)

[ ] Constantly/continuous. Present most of the time.

[ ] Intermittently. The pain comes and goes for periods of time.

Pain Quality:

How would you describe the pain? (choose as many adjectives as are applicable)

[ ] burning [ ] sharp [ ] cutting [ ] throbbing [ ] cramping [ ] numb

[ ] dull, aching [ ] pressure [ ] pins & needles [ ] shooting [ ] electric-like

Does the pain radiate anywhere? Where? ___________________________________________

_____________________________________________________________________________

Rate your Pain Intensity:

“0” = No pain “10” = worst pain imaginable

Circle the number below that best describes the WORST your pain level gets:

0_______1_______2_______3_______4_______5_______6_______7_______8_______9_______10

Circle the one number that best describes the BEST your pain level gets:

0_______1_______2_______3_______4_______5_______6_______7_______8_______9_______10

8/9/19 jvogel, revised 2/10/20

RELIEVING AND AGGRAVATING FACTORS

Activity Improves Pain Worsens Pain

Sitting

Standing

Walking

Driving

Bending

Turning

Twisting

Stretching

Looking up

Looking Down

Lying on back

Reclining

Laying on side

Support w/pillows

Ice application

Heat application

Changing position

Distraction

Relaxation/meditation

Doing something pleasant or fun

Resting

PREVIOUS PAIN TREATMENTS: Please check all of the treatments you have tried for your pain and then complete the appropriate column at the

right to the best of your ability.

Treatment Description Last time tried

Chiropractic

Physical Therapy

Biofeedback

Acupuncture

Dry Needling

Psychotherapy

Massage therapy

Ketamine infusion

Injections:

Joint

Spine

Radio Frequency Ablation

Trigger Point

Surgery: (list)

Other:

8/9/19 jvogel, revised 2/10/20

PREVIOUS DIAGNOSTIC STUDIES: Please indicate approximate date of most recent, if known:

MRI, CT scan, or X-rays:_______________________________________________________________________

EMG/NCV Studies:____________________________________________________________________________

MEDICATIONS: Check any medications you have EVER been on or are CURRENTLY taking:

NSAIDs Muscle Relaxant Adjuncts Short-Acting

Opiates

Long-Acting

Opiates

Migraine

Tylenol Flexeril

/cyclobenzaprine

Gabapentin

/Neurontin

Tramadol Tramadol ER Topamax

Ibuprofen Tizanidine

/Zanaflex

Lyrica Hydrocodone MS Contin Propranolol

Naproxen Baclofen amitriptylene Vicodin Morphabond Maxalt

Meloxicam Robaxin

/methocarbamol

Nortriptyline Norco Embeda Imitrex

/sumatriptan

Celebrex Norflex

/orphenadrine

Cymbalt

a/duloxetine

Percocet Avinza Amerge

Etodolac Skelaxin

/metalazone

Savella Oxycodone Oxycontin Zomig

Nabumetone soma Lidocaine Oxymorphone

/opana

XTampza ER Relpax

Diclofenac CBD Dilaudid Nucynta ER Amovig

Voltaren gel marijuana Hydromorphone Opana ER Emgality

Flector patch Gralise Nucynta

Exalgo ER Ajovy

toradol Horizant Codeine

Tylenol #3,#4

Fentanyl Botox

tegretol Levorphanol Butrans Fioricet

Subsys Belbuca

morphine Suboxone

methadone

Hysingla ER

Have you been given/prescribed a form of Narcan to use in case of emergency? ____Yes _____No

Pain Catastrophizing Scale (Copyright 1995, 2001, 2004, 2006, 2009 Michael JL Sullivan, PhD) Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.

We are interested in the types of thoughts and feeling that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain. Not at

all To a slight degree

To a moderate

degree

To a great

degree

All the time

I worry all the time about whether the pain will end 0 1 2 3 4

I feel I can’t go on 0 1 2 3 4

It’s terrible and I think it’s never going to get any better

0 1 2 3 4

It’s awful and I feel that it overwhelms me 0 1 2 3 4

I feel I can’t stand it anymore 0 1 2 3 4

I become afraid that the pain will get worse 0 1 2 3 4

I keep thinking of other painful events 0 1 2 3 4

I anxiously want the pain to go away 0 1 2 3 4

I can’t seem to keep it out of my mind 0 1 2 3 4

I keep thinking about how much it hurts 0 1 2 3 4

I keep thinking about how badly I want the pain to stop

0 1 2 3 4

There’s nothing I can do to reduce the intensity of the pain

0 1 2 3 4

I wonder whether something serious may happen 0 1 2 3 4

Matthews Vu Medical Group

PATIENT HEALTH QUESTIONNAIRE (PHQ-9) Name: Date:

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use "x" to indicate

your answer)

Not at all Several days More than Nearly

half the days every day

0 1 2 3

1) Little interest or pleasure in doing things 2) Feeling down, depressed, or hopeless

3) Trouble falling or staying asleep, or sleeping too

much 4) Feeling tired or having little energy 5) Poor appetite or overeating 6) Feeling bad about yourself or that you are a

failure, or have let yourself or your family down 7) Trouble concentrating on things, such as reading

the newspaper or watching television 8) Moving or speaking so slowly that other people

could have noticed; or the opposite, being so fidgety or restless that you have been moving around a lot more than usual

9) Thoughts that you would be better off dead or of hurting yourself in some way

Total Score:

Interpretation

Minimal Depression

Mild Depression

Moderate Depression

Moderately Severe Depression

Severe Depression

Interpretation of Total Score for Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

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Jvogel2/10/20

Functions Impacting Quality of Life Name: ___________________________ DOB: ________________ Date: ____________

Leisure Activities:

Activity Reading TV Computer Hobbies Exercise Puzzles/games Family/friends Social outside home

Time Spent

(hrs/day)

Sleep: (Circle all that apply to you)

Difficulty falling asleep Difficulty staying asleep Difficulty returning to sleep once awake

Sleep is disturbed by: pain thoughts anxiety bad dreams need to go to the bathroom

Total hours of sleep per night on average: less than 3 3-5 5-6 6-8

Work/Volunteer:

Unable at all Never thought about it _____ hours/day/week/month ____ days/month

Level of fatigue: (What best describes you most of the time?)

Bedridden have to rest 75% of the day have to rest half the day active on and off no problem as long as I pace myself

Motivation: (What best describes you?)

I have no desire to do anything I need constant push by someone else I can push myself to do things Motivated & ready

Safety: (Which best describes you?)

Unable to be left alone Need a lot of help Need some help Need no help/completely independent

Time Management: (Which best describes you?)

Rely on others to tell me what to do Need extra help often Need help sometimes Am self-directed and organized

Jvogel2/10/20

Functional Abilities Name: _____________________ DOB: ___________ Date: ___________

Put a check in the column that describes your function most of the time. “Not applicable” means this activity is not part of your life, e.g. you have no

children to care for or no sexual partner. “Unable to do” means you are incapable to doing.

Activity Not Applicable Unable to do

Even w/help

Difficult

Help needed

Extra Effort

Independent

Some Effort

Independent

Easy to do

Independent

Getting out of bed

Climbing stairs (1 flight)

Descending stairs (1 flight)

Getting out of a chair, hardback

Getting out of a chair, softback

Walking in the house

Walking outdoors, flat surface

Walking outdoors, uneven surface

Shopping

Personal care: shower or bath

Personal care: toileting

Personal care: dressing

Personal care: hair, teeth, nails

Daily activity: preparing meals

Daily activity: light housework

Daily activity: laundry

Daily activity: doing dishes

Daily activity: light yardwork

Daily activity: care of children

Driving

Sexual intimacy

Jvogel2/10/20

My Typical Day Name:________________________ DOB: _________________ Date: _____________

Please record your activities in a typical or average day—not your worst day or your best day.

Time of

Day

Description of Activity Amount of time in

activity

12AM

1

2

3

4

5

6

7

8

9

10

11

12 PM

1

2

3

4

5

6

7

8

9

10

11

8/6/19 jvogel revised 2/10/20

INTEGRATED PAIN CARE @ MATTHEWS-VU

NARCOTIC/OPIOD AGREEMENT

I, ____________________________, agree to the following expectations:

1. I understand that I am being prescribed strong medicine(s) and I have been informed of the common

side effects which I will promptly report to my prescribing provider if they occur.

2. I know I may become dependent or addicted to the medication(s). I agree to take the medicine(s)

exactly as prescribed and to not suddenly stop, increase, or decrease the medication without my

provider’s guidance due to possible life threatening withdrawal symptoms and/or overdose.

3. I have been instructed to avoid driving or operating machinery while taking the medication if it

makes me sleepy or dizzy.

4. I understand that the prescription will not be refilled early and I am responsible for properly taking

and safeguarding the medications. Any signs of misuse of the medication will be reason for the

prescriber to discontinue prescribing to me.

5. I agree that the medication(s) will be prescribed for no more than 30 days at a time by my prescriber

or one covering for him/her and at the time of my clinic/office appointment. Occasionally, an

exception may be made for patients whose insurance allows and demands use of mail order

pharmacy for 90 days prescriptions. Prescriptions will not be written outside of an office visit except

for compelling reasons documented in my medical record.

6. I agree to show up for my appointments at the office as scheduled. If I am late more than 15 minutes,

I will be asked to reschedule. If I cancel less than 24 hours in advance, it will be considered a “no-

show” and I may be charged a no-show fee for the missed visit. If I have more than 3 missed visits

within a six month period, I may be discharged from the program.

7. The treatment will be stopped immediately if I am found to be misusing the medication or using

other controlled substances, licit or illicit, not prescribed by my prescriber, including dentists,

emergency room providers, or surgeons unless authorized by my prescriber in advance.

8. No refills will be made on evenings, weekends, holidays, or by phone unless this has been planned in

advance with the provider.

9. I will use only the following pharmacy to fill all my prescriptions unless that pharmacy is unable to

fill the prescription in a timely manner or I contact my provider regarding a reason for change of

pharmacy:

Pharmacy name: _________________________________________________________________

City: ____________________________ Phone: ________________________________________

8/6/19 jvogel revised 2/10/20

10. I understand that lost, stolen, or damaged medications will not be replaced.

11. I agree not to sell, lend, or share my medications with any other person.

12. I agree to not use any illegal drugs and to use alcohol only in moderation.

13. I agree to submit to drug testing at any time requested.

14. I agree to participate in test, other treatments (exercise, physical therapy, behavioral therapy,

rehabilitation, etc.) or evaluations by other specialists as recommended by my provider and to

cooperate fully in my treatment plan for chronic pain.

15. I am not pregnant at this time and will avoid becoming pregnant while taking this medication as far

as I am able.

16. I agree that I am not currently using illegal drugs and have never been involved in the sale, illegal

possession, diversion, or transport of a controlled substance.

17. I understand I may use marijuana only if I have a license to use medical marijuana and am

responsible for renewing this license annually as long as I use any products containing THC or

cannabis including CBD with THC.

17. If any of the above rules and agreements are broken, my medication(s) may be stopped without

advance notice and I understand I may be discharged from the practice.

Patient Name: __________________________ Signature: _____________________ Date: ________

Provider: __________________________ Signature: _________________________ Date: ________

Witness: __________________________ Signature: _________________________ Date: _________